Basic Information
| Provider Information | |||||||||
| NPI: | 1104829183 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENDERSON CLINIC FOR WOMEN PA | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HENDERSON CLINIC FOR WOMEN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 511 RUIN CREEK RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275365919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524928576 | ||||||||
| FaxNumber: | 2524927464 | ||||||||
| Practice Location | |||||||||
| Address1: | 511 RUIN CREEK RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275365919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524928576 | ||||||||
| FaxNumber: | 2524927464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2524928576 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 39877 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 89-01757 | 05 | NC | MEDICAID | 7808539 | 01 | NC | AETNA GROUP ID | OTHER | 16402 | 01 | NC | WELLPATH GROUP ID | OTHER |